Pyeloplasty techniques using minimally invasive surgery (MIS) in pediatric patients

Preliminary results of feasibility, safety and efficacy of robotic assisted laparoscopic pyeloplasty with the SHURUI single-port robotic surgical platform in children

This study aims to evaluate the feasibility, safety and efficacy of robotic assisted laparoscopic pyeloplasty (RALP) with the novel SHURUI single-port (SR-SP) robotic surgical platform in children. Between November 2023 and April 2024, 20 pediatric patients diagnosed with ureteropelvic junction obstruction (UPJO) underwent transperitoneal RALP with the SR-SP surgical platform. Baseline characteristics, perioperative parameters and follow-up data were collected and analyzed. All surgical procedures were successfully performed without conversion to open or laparoscopic surgery. The median docking time, console time, and operative time were 3.5 min (range 3.5-6.0), 144.5 min (range 88.0-290.0), and 221.5 min (range 136.0-450.0), respectively. The median estimated blood loss was 5 ml (range 2-20) and the median length of hospital stays was 6 days (range 4-24). Through trans-umbilical incision, RALP was feasible in patients with a height of no less than 114 cm. The minimum incision length was 2 cm. No intraoperative complication was identified. Two cases were identified with the Clavien-Dindo Grade II postoperative complications and one with the Clavien-Dindo Grade III complications. The surgical success rate was 95%. The median SCAR scale score for incision scars was 2 points (range 1-3). Surgeons reported a favorable technical difficulty rating with a National Aeronautics and Space Administration Task Load Index (NASA-TLX) score of 30.7. RALP using the novel SR-SP robotic surgical platform is feasible, safe and effective in older children. The SR-SP surgical platform may serve as a promising alternative to the da Vinci SP surgical platform.

COMPARISON OF LAPAROSCOPIC AND OPEN PYELOPLASTY IMPACT ON COMFORT AND SUCCESS: A RETROSPECTIVE, SINGLE CENTER STUDY

Ureteropelvic junction obstruction causes hydronephrosis and may lead to renal parenchymal damage unless timely diagnosed and treated. Although open pyeloplasty is still the gold standard, it needs to be compared with new techniques. In this study, we compared laparoscopic and open pyeloplasty. Data on 113 patients who had undergone surgery between 2008 and 2014 were evaluated retrospectively. Thirty-nine patients had undergone laparoscopic pyeloplasty, and 74 had undergone open pyeloplasty. Ultrasonography was performed at 3 months and scintigraphy at 6 months postoperatively. Parameters such as the length of surgery, need for analgesics, length of hospital stay, complications, and success rates were compared. When compared to open pyeloplasty (mean 9.8 dexketoprofen 50 mg IV dose), the need for an analgesic was significantly lower in the laparoscopic pyeloplasty (mean 4.5, paracetamol 15 mg/kg IV dose) group (p<0.05). The length of hospital stay was also shorter in the laparoscopic pyeloplasty group (mean 4.0 days) than in the open pyeloplasty group (mean 7.3 days) (p<0.05). This study demonstrated that laparoscopic pyeloplasty could be safely used in the treatment of ureteropelvic junction obstruction with a lower need for analgesics and a shorter length of hospital stay than with open pyeloplasty.

Effectiveness of a Laparoscopic Training Model for Pediatric Surgeons During COVID-19 Pandemic: A Single-Center Experience

Background: During COVID-19 pandemic, many restrictions were applied in the field of health care. For this reason, we decided to adopt the laparoscopic simulator Laparo^® Analytic to allow the trainees of our pediatric surgery training program to continue their training activity, and we determined its impact on their surgical education. Methods: We used Laparo Analytic Simulator for laparoscopic surgery training among the residents of our center. Fifteen residents from different years of the pediatric surgery program participated in this study. Each participant performed a 2-hour training session per week, consisting of three different exercises: Rubber Bands, Knotting, and Suturing. For each training session, the following parameters were analyzed: training time, economy of movement, smoothness, instrument activity (IA), instrument visibility (IV), and instrument symmetry. Results: Results were collected after the first training session (T₀), at 3 months after the beginning of the study (T₁) and at 6 months after the beginning of the study (T₂). At T₂ of training with Laparo Analytic Simulator, residents were able to complete their tasks significantly faster (P = .001) and had a significant improvement in smoothness of movements, IA, IV, and instrument symmetric movements during the tasks analyzed. Conclusion: On the basis of our results, we believe that Laparo analytic is an excellent system to adopt in minimally invasive surgery (MIS) training programs, in particular, during periods of surgical restrictions, as COVID-19 pandemic, or in centers with a limited MIS activity.

Quality of YouTube Videos on Laparoscopic Pyeloplasty in Children: An Independent Assessment by Two Pediatric Surgeons

Background YouTube (YT) is the most common video platform accessed by surgical trainees for the preparation of surgery. However, the quality of the YT videos has been questioned time and again. This study was performed to comprehensively assess the quality of the available YT videos on pediatric laparoscopic pyeloplasty (LP). Materials and Methods The term "laparoscopic pyeloplasty in children" was searched in YT on June 3, 2021, and ten most-viewed videos on LP were included. The percentage video power index (%VPI), the Journal of American Medical Association (JAMA) benchmark criteria, and the laparoscopic surgery video educational guidelines (LAP-VEGaS) video assessment tool were used to assess the video popularity, the quality of medical information, and the overall quality of the included videos respectively. Videos were defined as acceptable (score of 11 or more) or poor quality (score <11) based on LAP-VEGaS scores. The inter-observer agreement, in terms of the LAP-VEGaS scoring, was observed among two surgeons using the kappa statistics. Results The median values of the %VPI and JAMA scores of the included YT videos were 68.1 (range 0-13570) and 2 (range 1-2) respectively. The median LAP-VEGaS score of these videos was 6.75 (range 2-16.5) with only two videos having acceptable quality. The quality of these videos was poor in 7/9 domains of the LAP-VEGaS tool. A moderate inter-observer agreement (kappa=0.542) was observed in terms of the LAP-VEGaS scores assigned to the videos (p<0.0001). Conclusion A comprehensive assessment of the ten most-viewed YT videos on pediatric LP revealed poor overall quality. The included videos depicted sub-optimal presentation of the medical information and weak conformity to the LAP-VEGaS guidelines.

Minimal Invasive Treatment in Pelvic-Ureteric Junction Obstruction: A Comprehensive Review

Pelvic-ureteric junction obstruction (PUJO) is a common condition, and one of the lead causes of hydronephrosis in children. Currently, the gold standard treatment of PUJO is open surgery using the Anderson–Hynes-modified dismembered pyeloplasty technique. However, with the advancement of medical technology, several minimal invasive approaches were developed, including endoscopic, laparoscopic, and robotic approach, from which the best choice of surgical technique was yet to be determined. Considering the advantages and disadvantages of these methods, the recommended option is to tailor the best surgical approach to each individual patient, and to the surgeons’ preference and experience. Considering these recent advances, a new algorithm is proposed to choose the best minimal invasive modalities invasive treatment to treat PUJO.

Meta-analysis of retroperitoneal vs transperitoneal laparoscopic and robot-assisted pyeloplasty for the management of pelvi-ureteric junction obstruction

OBJECTIVE

To determine differences in perioperative outcomes between retroperitoneal and transperitoneal approaches for laparoscopic pyeloplasty (LP) to manage pelvi-ureteric junction obstruction (PUJO) through a meta-analysis of comparative studies.

METHODS

A systematic search was performed in January 2020. Comparative studies were evaluated according to Cochrane Collaboration recommendations. Assessed outcomes included success and complication rates, conversion to open surgery, operative time (OT), length of hospital stay (LOS), estimated blood loss (EBL), analgesic requirements, regular diet resumption, and drain duration. Relative risk (RR) and standardised mean difference (SMD) with 95% confidence intervals (CIs) were extrapolated. Subgroup analyses were performed according to study design and techniques. International Prospective Register of Systematic Reviews (PROSPERO) number: CRD42020163303.

RESULTS

A total of 18 studies describing 2007 cases were included. Overall pooled effect estimates did not show statistically significant differences between the approaches with regards to success rate (RR 0.99; 95% CI 0.97, 1.01), complications (RR 1.09; 95% CI 0.82, 1.45), OT (SMD 0.61; 95% CI -0.04, 1.26), LOS (SMD -0.30; 95% CI -0.63, 0.04), EBL (SMD -0.53; 95% CI -1.26, 0.21), or analgesic requirements (SMD -0.51; 95% CI -1.23, 0.21). Compared to the transperitoneal approach, retroperitoneal LP had a higher conversion rate (RR 2.40; 95% CI 1.23, 4.66); however, patients resumed diets earlier (SMD -2.49; 95% CI -4.17, -0.82) and had shorter drain duration (SMD -0.31; 95% CI -0.57, -0.05).

CONCLUSION

The evidence suggests that there are no significant differences in success rate, OT and complications between transperitoneal and retroperitoneal LP. Conversion rates are higher with the retroperitoneal approach; however, return to diet occurs faster and drain duration is shorter when compared to the transperitoneal approach.

Evaluation of the clinical value of retroperitoneal laparoscopic pyeloplasty in the treatment of ureteropelvic junction obstruction in infants: A single-center experience involving 22 consecutive patients

Retroperitoneal laparoscopic pyeloplasty (RLP) is 1 method for treating ureteropelvic junction obstruction (UPJO) in children, but reports are more common in children than in infants younger than 2 years old. The purpose of this study was to evaluate the clinical value of RLP for infants with UPJO.From January 2015 to December 2017, a retrospective analysis of 22 infants aged 2 to 24 (11.95 ± 6.00) months with UPJO who were treated with RLP in our hospital was performed. During the same period, 14 infants who underwent conventional transperitoneal laparoscopic pyeloplasty (TLP) were compared with those who underwent RLP. Postoperative recovery and complications, including bleeding, infection, urinary leakage and anastomotic stenosis, postoperative resumption of oral feeding, postoperative hospitalization time and surgical success rate were evaluated. Drainage and function were assessed with isotope scan at 6 months and later during the yearly follow-up and by intravenous urography (IVU) and mercaptoacetyltriglycine (MAG3) renography.Both groups underwent successful surgery. The operative time in the RLP group was 88 to 205 (120.59 ± 24.59) min, and there was no significant difference compared with the TLP group (P = .767). The estimated intraoperative blood loss was 2 to 10 (3.75 ± 1.59) ml, which was not significantly different between the 2 groups (P = .386). In the RLP group, the mean postoperative resumption of oral feeding was faster than that in the TLP group (3.55 ± 0.74 vs 5.50 ± 0.85 hour, P < .001), and the postoperative hospitalization time was shorter in the TLP group than in the RLP group (6.59 ± 0.50 vs 7.07 ± 0.47 day, P = .007 < .05). Follow-up lasted from 6 months to 3 years, and there was a significant reduction in postoperative hydronephrosis in both groups (P < .05, respectively).RLP is a safe procedure for infants. This procedure is associated with relatively little trauma, a quick recovery and good cosmetic effects. RLP also has the advantages of relatively little interference with the abdominal cavity and sufficient operating space; thus, this technique is worth promoting.

Stones First! A Gas Pyelo-nephroscopy Strategy for Laparoscopic Pyeloplasty and Renal Stone Extraction

OBJECTIVE

To report our experience on gas endoscopy as the first step of pelvi-ureteric junction (PUJ) obstruction repair when complicated by nephrolithiasis.

MATERIALS AND METHODS

Stone formation because of urine stasis is a known complication of PUJ obstruction and an indication for its surgical repair. The undisputed results of the Anderson-Hynes dismembered pyeloplasty make it a quasi-gold standard; however, the identification and extraction of calyceal stones through the laparoscopic route can be challenging. Between 2009 and 2016, 39 patients underwent laparoscopic pyeloplasty at Ygia Polyclinic, with a subgroup of 6 patients having concomitant calyceal stones. These 6 patients first underwent gas pyelo-nephroscopy before dismembering the PUJ. Demographic data, intraoperative technical details, outcomes, as well as postoperative outcomes, were collected and analyzed.

RESULTS

We report a small series (n = 6) with 3 minor modifications of the laparoscopic repair of PUJ obstruction complicated by stones. One modification is to carry out a pyelo-nephroscopy for stone extraction before dismembering the junction. The second modification is the use of gas medium to distend the renal cavity, and the third is the use of a flexible cystoscope. Postoperative recovery was uncomplicated in all 6 patients, with successful relief of the PUJ obstruction and stable stone free results demonstrated on follow-up for all patients.

CONCLUSION

We claim that these modifications overcome the usual challenges related to working in a collapsed cavity and using fluid media, while achieving desirable outcomes.